Provider Demographics
NPI:1356791834
Name:DEWOLF, MARK ANTHONY (MA, LPC, NCC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANTHONY
Last Name:DEWOLF
Suffix:
Gender:M
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:MAHADEV
Other - Middle Name:ANTHONY
Other - Last Name:DEWOLF
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, LPC, NCC
Mailing Address - Street 1:8050 NIWOT RD APT 3
Mailing Address - Street 2:
Mailing Address - City:NIWOT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-8690
Mailing Address - Country:US
Mailing Address - Phone:970-470-1240
Mailing Address - Fax:
Practice Address - Street 1:3333 IRIS AVE STE 210
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1998
Practice Address - Country:US
Practice Address - Phone:970-470-1240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0015925101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty